GW1--01329_Well Construction - GW1_20240304

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WELL CONSTRUCTION RECORD .
For,tuMfaall Vse ONLY.;
This form can be used fit single cit multiple mils- -• - -
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1.'Weil:COntraCtor Information:
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• . • . • t;41.WATER ZONES . . . - I . . •
Tyler.Brown • - • •
. .. . FROM - 'DESCRIPTION
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Wen Cetitactoi.Naine ft,: . I
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. •4625A - .ft. . ft.
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NC,Weal Contractor Ccrtifteelleil Nutitier ' . 'AS.OUTER:CASING CIOrtnitftljaietIaills).°MINER(if-tilt Rabic): '
. • • FROM TO .- • DTAATEIRR.•t . THICKNESS. . ARTERIAL•
' •SAEDACCO .0 ft, 17 ft.. .2 tn.• SCH-4 0 PVC
Caltkpally qq111P ' . - . .I6ANNERCASING•OR TIMING.militant:0 ciltitsk_ILet).,'"
. -.. FROM TO. _ DRATETER . THICKNESS MATERIAL • • .
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2.WelirtornOtrition Rettnit lir . . . ' . .. ." . . .-'ft: . •• ft:' •, 'in.- .-
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List 4/Rapp/lea/If isuirpeauftlft‘u.County.•Stiee.Vorlawe.filedal ere:). .
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3.Welt tAb(chcell:*tiltrso): . ' .
It S(:REEN
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- FROM, . TO . l''DIAMETER •SLOTSITE. THICKNESS. I MATHRIAL
Water Supply Well: - • . . .
. . . . 17 ft.. 27 'ft.• .2 . 111.• •I:.010 • SCR-40 PVC
, . .lattgriauitittal - - - CligunidipaliPublit . .
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ft. . •,„ . .
1:1Geotheitnat(HeatingCcroii rig Supply} E:Residentiat Water Supply(single) : ft. M. ;
,ClIndusttialf.Conuttorcial - CiResidentiat-Witter Supply(sual'- wo- )
FRONI — TO • .-MATERTAL-.'• . ENIPLACEMENT AIEMOD&AMOUNT
. . Llitiieation . . • .
. , .0 .ft.• •11 - .ft. Bentonite c 'e• .
'Ntin-Water SuPpli Well:: ' • • - • . . . .
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It..., ' . tt.-
- Monitoring . . . : PRecoyety . . • . • . I •
• . Injection Welt:.- • . • • • • , . . • • ft.- • •Jt. . , . - • • • • - •
IZIAgniferEcchlitge • . • ' ' • Lifliptitidwater RcniediatiOn' • : -,19:SANDiGHAVEL•PACRtitupplieubter • • •..-, - •
• -,, -• :• ' •• —FROM. " TO• • A fAriltrAl, ' ' - FAIN ALIMENT MIA11011 • - .
PArpri(CiStoragkand kccovety • - 1:35alittily Barrier' 15 .11.. 27 ft.: Gravel pack #2 • ., • . - . .
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I3AquifcrTest . 1:1Sionnwatet firairiage ft
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itiaperinientql Teclitioloa . OSttbsict*c Control • . - - • • - •• • . ' '* •
la.,DRILLING'LOG fiiitach additional:slice&if hecessani ' ' • . -
bereodrestual(Closed Loop) • - ElTracer. . • - . ' •. .vriost•: TO . DESCRIPTION II/Abk ItlintneAC wilhitek bistv-Pviill site.deo,' • • •
balultertual(11eUtingiteoling Return) ' 1:10ther(erniairt under.42 a Rettiarks) . -'ft•• . rt.. - i , . . .
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' - • ft.. ft. • " ' . .
4 R
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. . . . are Well(s)ComplOted: 2-15-24 .Well ID#mr"1-8 • •
. , . .. . . . -11- " . ft-- • ' ,..--.?"''..;r''f'V i...--.n.
r'7";••;,,„, %,......1.
Sa.Well Location: • , . ,ft. .. . ft. l°, '4 A..—‘--1 L—1 • -"""'-'
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Kayser Roth . ' • • • - ft, .. . 4 .2024
, • . FactlitykDittmriimix • ' - Facility ID!!litappiiaable) . ' _ ._ — _
It; - ft.- - -• ' • I • •
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- 714 1-40 Graham, NC,.27253' . .
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' ' - • 'ft. • -ft.. tsvforivaa:,i, .......
vtfCii•BOG
. . . . • : - . . -PI64ical•iiidi-.*Ct.-and Zip.. '2 t...REM,I.Rft..i, - • .
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• • • . .Bentonite seal 11'-15' ' I, . . . •
- - Alamance-- • • • • . .
, .GK.Aitily. . • . •. . • Nrcel Itletilificallint No,.(111N) . . • • . .
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Str,,X._,Atitirde.arirl Liingitiadc in degrcestminuteitScoinds Or dcebial degilies-: 22.6,tiffitui•on,•, • . . I, . . .
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rtrii ne oiletatileit is'solftelei4) • . , •
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• r.D.,
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N • . W- Er..),djY/P- 2/19/2024
' . e:dfCeitirted Well Centractot I . • : Dale . .
. . 6.Is(ire)thec110: X1Petutanent .or DTemporary •. . . . . . .1. . . .
. . • •ny 3igning ifris feurrri.I hereto cerrYy thqf 11101r4I(y)tiriS fr-rnt LW/girlie/Ed in.arcordon.cr
' ititft FM NC1IC OW.0100 or ISA hICACO2C.0200 We Coitstrnlericur SfoOdanis and ilia •
- . 7.Is this a repair firan.e.xistimir Well: , ElYpi or -12No • "realyiif Mk ward.Ina peen providedra en;-In-ili Owner. . .
- . ljn'olsix G re,mOr;fill oat koaivn wvIreang;in-don If:favour:Ion awl explain the narare of rite ._ ' •
. - repoir ander 021 irnianEvrciicin or bn the bail 4010 Pim. 23.Site tliagrattebr additional well detitlis ' . : .. • . • .
• - - . . You tunymo.the back of this page to,provide additional well site detail's or:ire)) -- •
, eousttuction.details. You inay alto attach additional page's if necessary, • -8.Nnerther of wells constricted: 1 . . .
Far nto101de infeeilan.i.-non-1.earer inppti•leells ONLY with dle satnecanstruetion,;,,an on __,. . I• - . , '
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stilmituanff fottp. ", - SUIINtrrrAL INSTUCTIONS- ; . •
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9.-Ifotal well depth beton,hind surface; 27 - - . ff1) -21;r.•Fur All Wells.:. Suhinit this form within,30 days of:completion.of welt •
For maniple iee11111.s- r off d'epky ildtOirent(examlep -3€1200`awn@ IVO) eonstructiOn to the following: • I
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10.Static water level below top of easing;;- ; • • - Diviiiion of Water Resources,information Processing Unit,'
Ievel Is above cosing:ore''+" . '. 1417 hLtil,Service Cetitc ,11aleti4t,NC 276991611 •. • -
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• • 11:Borehotelliametcr:67 . . '...-(in.) 21b.For fOJection Walla ONLY: In addition to sending the forum to the address in
24a above.also.submit a;copy of this.lforot within 30 days,of completion of tall
12.Well conStrnetion'method:Rote-sonic; . construction to the foiloWing: '
(i.e:aug.er.•mem,cable,direct gash.Mc.) ' '• . . . . . i ,
Dlirislun of Water Resources.-Underground fujectiott,ContrOl Program;
FOR WATER SUPPLY WELLS ONLY: - • ' 1636 Mall Service Center...Raleigh,NC 27499-1636
• • 24e...For-WaterSupply..tit Injection Wells: •
12a.Yield(gpm) Method'of test: • •
' Also'subtnit one col*-Or thiS forum Within 30.days or c:otilAtion.of •
13h.Disinfecitlim knie.: . • • Amount;. .. r -. . well-'construction to the cOnnty health!department.of the.Connti.Where
- constrocieil. I
-Fortri.GW-I No' rth Carolina.Dgertitent of Envitanmetit attd Natural Resources-Division of Water itetart6 Revised August2013 . -
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